ARIZONA DEPARTMENT OF PUBLIC SAFETY



ARIZONA DEPARTMENT OF PUBLIC SAFETY FOR DPS USE ONLY

SECURITY GUARD FIREARMS-SAFETY Instructor #

INSTRUCTOR APPLICATION

NEW APPLICATION RENEWAL

Arizona Department of Public Safety - Licensing Unit

PO Box 6328 MD 3140, Phoenix, AZ 85005-6328

Please include the $50.00 application fee and a copy of your firearm instructor credentials.

The DPS Licensing unit can only accept cash, money orders, and cashier’s checks.

PLEASE INCLUDE A PHOTOCOPY OF A GOVERNMENT ISSUED IDENTIFICATION CARD: Driver’s license, Passport, Etc.

THIS SECTION TO BE COMPLETED BY APPLICANT/INSTRUCTOR

LAST NAME FIRST NAME MIDDLE NAME

DRIVERS LICENSE OR ID NUMBER STATE OF ISSUANCE SOCIAL SECURITY NUMBER

GENDER: MALE DATE OF BIRTH (MM/DD/YYYY) STATE / COUNTRY OF BIRTH ORIGIN / RACE HEIGHT WEIGHT EYE COLOR HAIR COLOR

FEMALE

HOME STREET ADDRESS APT. NO. CITY STATE ZIP CODE

MAILING ADDRESS (STREET OR P.O. BOX) APT. NO. CITY STATE ZIP CODE

HOME PHONE CELL PHONE BUSINESS PHONE E-MAIL ADDRESS

Please check “YES” or “NO” to each question below

YES NO

Are you a resident of Arizona or a United States citizen? If NO, you do not meet the requirements for obtaining an armed security guard training instructor certificate.

Are you currently under indictment for a felony arrest or have you ever been convicted of a felony offense? If Yes, you do not meet the requirements for obtaining an armed security guard training instructor certificate.

Do you suffer from mental illness and have been adjudicated as mentally incompetent or committed to a mental institution? If Yes, you do not meet the requirements for obtaining an armed security guard training instructor certificate.

Do you meet all of the qualifications of a firearms-safety instructor listed in administrative rules Title 13, Chapter 6, Article 7, R-13-6-701.

Did you include $50.00 in cash, money order, or cashier’s check made payable to DPS for the Security Guard Firearms-Safety Instructor processing fee in your application packet?

Did you include a current copy of the front of your NRA card showing the expiration date, Arizona POST certification, or Federal firearms certification in your application packet?

I attest that, to the best of my knowledge, all answers on this application are true. I understand that I may be subject to criminal prosecution for falsification or misrepresentation of any document provided to DPS in the application process. I understand that falsification or misrepresentation is grounds for denial or revocation of instructor approval.

Applicant Signature DATE

FOR DPS USE ONLY FOR DPS USE ONLY FOR DPS USE ONLY Rev 06-28-2016

Issue Date: Exp. Date: BADGE # DATE RECEIVED

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